Healthcare Provider Details

I. General information

NPI: 1053034041
Provider Name (Legal Business Name): LOS ANGELES HEMATOLOGY-ONCOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ALESSANDRO PL STE 310
PASADENA CA
91105-4000
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 626-288-0008
  • Fax: 866-741-4630
Mailing address:
  • Phone: 323-794-1403
  • Fax: 323-488-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARLA LOU WSIAKI
Title or Position: PROJECT MANAGER
Credential:
Phone: 323-254-0046